False Move From ‘Urgent’ to ‘Emergency’ Care

When a woman asked Trudy Lieberman, a professor of public health, if urgent care centers affiliated with hospital emergency departments “ever try to escalate patients to the ER when it is not medically necessary,” the answer, in a nutshell, was “Yes.”

In many other industries, persuading a customer to buy more than what he or she intended or needed is known as “upselling.” It happens a lot in medicine, too.

This example, recounted by Lieberman on KevinMD.com, involved a mother who took her son to an urgent care center over the July 4th weekend to be seen for headache, nausea, abdominal pain and vomiting. Because the kid isn’t a complainer, mom thought he might be really ill. The clerk asked about his symptoms, then quickly referred him to the emergency room across the street. It was part of the same hospital system as the urgent care center.

The clerk, not a doctor, nurse or physician’s assistant, said that because the son had abdominal pain, he needed a CT scan, a diagnostic procedure the urgent care center was incapable of performing.

The mom’s insurance coverage had a co-pay of $75 for urgent care treatment. The co-pay at the hospital ER was $250. The mother was skeptical about the “upsell,” because she knew that CT scans often are overused, especially in emergency rooms. The device uses multiple X-rays to create an image that can increase radiation more than 1,000 higher than a conventional X-ray.

“In today’s ERs,” writes Lieberman, who teaches at Hunter College in New York, “patients are getting scans at rates five times higher than in the mid-1990s.”

In addition to wasting money and health-care resources, that’s a lot of unnecessary radiation for patients who don’t need it. Enlightened doctors (and the ones who don’t have financial interests in diagnostic imagery equipment) lobby for more discretion in the use of this technology. (See our blog, “Doctors Call for Lowering Use of Radiation Imaging.”)

Lieberman revisits the reasons for justifying the overuse and overdosing of CT scans – doctors’ fears of malpractice claims if they don’t take every measure, and pressure on facilities to use expensive equipment in which they have a large investment.

Was the urgent care center to which the mother took her son motivated to send him to its sister hospital’s ER to juice revenue? Well, consider this: The two hospital systems in their city of about 100,000 people are aggressively competing for business. Each one has a fancy, technology-stuffed new emergency room.

“If cross-marketing of services works in banking and other industries,” Lieberman asks, “why wouldn’t it work in hospitals? Worried moms just might bite and take their kids across the street for a CT scan, especially if the required co-pay or co-insurance were not a drain on the pocketbook.”

The mother declined to take her son across the street.

Because her son was not having an acute emergency, she took the time to take him to another urgent care center not affiliated with either hospital system. It accepted her $75 co-pay, and her son was examined by a physician’s assistant, who did all the right things: ask about his symptoms, feel his abdomen and diagnose gastroenteritis.

That’s a broad term that can include infection or irritation of the digestive tract, especially the stomach and intestine, that usually lasts a few days. Adults usually recover on their own; children, the elderly and people with underlying disease might need more treatment.

The physician’s assistant prescribed anti-nausea medication for the boy. He was fine in a couple of days.

If you find yourself in an urgent care center that seems overly quick to send you to a higher level of care without an exam, especially if it’s affiliated with the facility they’re sending you to, unless you have a true emergency, find out why they’re so keen to get rid of you. It’s possible, maybe even likely, that it has nothing to do with solving your problem the quickest, best way.

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